Company Statement
For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.
Director, Contracting and Compliance
Directs and coordinates ConnectiCare’s compliance activities to ensure ongoing compliance with applicable state and federal laws and regulations. Manages the contract compliance program.
Responsibilities:
- Manages and negotiates terms of selected contractual agreements with hospitals, physicians or ancillary providers. Negotiates rates within or better than the annual Plan.
- Develops, implements, and maintains an effective contract compliance program which includes a rating system to assure all contracts meet business requirements.
- Coordinates and facilitates audits and reviews on contracts to assure they meet organizational requirements.
- Responds to any deficiencies; monitors preparation and execution of corrective action plans.
- Oversees implementation of ConnectiCare's strategic plans related to contracted healthcare delivery systems within assigned networks and geographic expansion.
- Hires, develops, manages, evaluates, and motivates at least one staff member.
- Works with other departments to identify contracting opportunities and implements workplan for special projects as needed.
- Conducts monitoring and auditing activities to identify and assess areas of contract compliance risk for the organization as well as, assure all agreements are compliant with state laws, federal laws, and NCQA.
- Makes self-reporting determinations and periodically reports to Senior Management on significant contract compliance results, risks, and key activities.
- Reviews and approves pertinent corporate and business unit policies, procedures and workflows to assure contracts are meeting all business requests.
- Performs other related projects and duties as assigned.
Qualifications:
- Bachelor’s Degree
- Master’s preferred
- At least 10 years experience in a combination of contracting, and managed care with an understanding of the importance of regulatory reviews and processes followed by Department of Insurance, NCQA and State entities required
- Excellent organizational and planning skills; line and matrix management skills required
- Ability to function productively in a multidisciplinary, relatively unstructured environment required
- Excellent analytical and problem solving skills to identify root cause deficiencies in regulatory compliance and develop corrective action plans required
- Excellent written and oral communication skills with demonstrated ability to interpret government regulations; develop and deliver training and monitoring programs required
- Excellent negotiation/influencing skills, with all levels (internal and external) required
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.